MEDICARE: LISA MARIE PARK FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	117804	WV

General Provider Information

NPI Number	:	1639944382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE PARK FNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 285
Second Line	:
City	:	TRIADELPHIA
State	:	WV
Zip	:	26059-0285
Country	:	US
Telephone Number	:	304-639-0873
Fax Number	:

Provider Business Practice Location Address
First Line	:	4509 NATIONAL RD
Second Line	:
City	:	TRIADELPHIA
State	:	WV
Zip	:	26059-2013
Country	:	US
Telephone Number	:	304-639-0873
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2023
Last Update Date	:	11/21/2023

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Directions to “ LISA MARIE PARK FNP-BC” Practice Location

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